Regional anaesthesia: what matters?

Michael Barrington

Training  and Education

Training in regional anaesthesia is often conducted in an ad-hoc manner related to the availability of both surgical cases appropriate for regional anaesthesia and individuals with appropriate expertise in the field. Many studies on training in regional anaesthesia have focused on a minimum number of procedures required to achieve competency. In many training scenarios, the recommended number of cases is simply not available. An alternative approach is to structure training so that it follows valid educational principles that are relevant to motor skills training in regional anaesthesia. (1)

A. Creating the pre-trained novice:

Ultrasound-guided nerve block procedures comprise discreet component tasks that when deconstructed provide a basis for teaching, learning and assessment of skills. In the motor skill learning literature, fractionization refers to practising a discreet component of a complex motor skill separately. (2) Acquiring relevant sonograms and identifying anatomical structures is a discreet component skill required for ultrasound-guided regional anaesthesia. A second key component skill is needle-guidance under ultrasound. Both sonography and needling skills can be practiced in a non-clinical environment and then combined with other skills and knowledge to perform a clinical procedure.

Learning motor skills in an environment remote from the operating room and clinical responsibilities has merit. As a motor skill, sonography skills required for regional anaesthesia are relatively complex requiring a high level of cognitive involvement. During an early stage of their training, trainees should become familiar with task demands and acquire and develop a degree of automaticity in the core psychomotor skills required for specific procedures before performing them on patients. When a trainee then performs the procedure in the clinical environment it then requires less attentional capacity and information processing for the core skills as these would have been developed during their prior part- task training. The trainees’ attention could then be more fully committed to higher-order processes and developing key attributes including communication, team-working, planning and decision making. (3)

B. Deliberate practice:

This is required to create the pre-trained novice ready for regional anaesthesia and to further develop practitioners with wide levels of expertise. It is likely that anyone, regardless of expertise will benefit from deliberate practice. The key point is that an expert will be practicing a different task to that practiced by the novice. The validity of deliberate practice has been demonstrated in many fields including music, chess, sport and medicine. The term deliberate practice does not appear commonly in the anaesthetic literature, however in a recent edition of Anesthesia and Analgesia, there is a review article on deliberate practice. (4)

An example of the benefits of deliberate practice is demonstrated in the following example. Ten University of Melbourne Doctor of Medicine students, all novices to ultrasound, had their sonographic proficiency assessed in a structured teaching environment. Proficiency was measured by the novices ability to acquire and interpret sonograms required for ultrasound- guided axillary brachial plexus block. Figure 1. demonstrates that within 8 – 10 supervised scanning sessions that included feedback; novice participants achieved sonographic proficiency (maximum score possible, 18) at this anatomical site.


Figure  1.  Group  median  (and  interquartile  range)  of  ‘Sonographic  Proficiency  Scores’  versus  Scanning Session for massed (—+—) and distributed (—[gj —) groups.

C. Preoperative briefing/debrief:

This can set the goals for the learning exercise (procedure) and set out the boundaries for what tasks will be done by whom.   The briefing can assess the trainee’s knowledge  and  a  standard  dialogue  can  be  used.  This  is  a  dialogue  that  I  commonly  use  for  a registrar  before  performing  a  procedure.    This  assesses  the  trainees  knowledge  in  advance  of assessment of procedural skills required for trainee Work-based assessments. (5)

Pre-procedure interview (away from patient)

1. What is the name of the block and what is the indication for the block?
2. What are the most important anatomical landmarks?
(Provide clues if necessary: Nerves, vessels, muscles, fascial planes if relevant)
3. What sensory and motor blockade will the block produce?
4. Assume I am the patient. Please provide me with information that I require to make an informed decision and be able to consent (or not) to this block procedure.
(Provide clues if necessary: Side effects, risks and complications)
5. What monitoring are you going to use during the block?
6. What probe are you going to use?
(If trainee states anything other than high or intermediate frequency/ linear probe, ask for further explanation).
7. Patient is …kg:
What are you going to inject and what volume and concentration? What needle type?
8. Post-procedure management:

How are you going to test the success of the block?

If the block is unsuccessful (or incomplete) what are you going to do (assuming you still plan to proceed for surgery)?

If the block is successful what instructions are you going to give the patient and the nurse looking after the patient, after the operation?
The preoperative briefing can be used to discuss a wide range of logistical, generic clinical and hospital-specific issues relating to a particular case. Feedback given to a trainee when a procedure is completed can track back to learning objectives.

D. Educational concepts to consider during and immediately following a procedure:

a. Learning versus performance - performance of a motor skill is a measure of immediate aptitude. If a learning session leads to a sustained improvement in performance then learning has occurred. During a teaching session, improvement in a measurable aspect of a registrar’s performance does not necessarily reflect learning. For learning to occur the improvement must persist or be transferrable to other skills.

b. Concurrent feedback - Feedback delivered during the performance of a skill. Concurrent feedback may be required for a novice however; if feedback is delivered during the procedure it may inhibit learning of an intermediate practitioner. In this setting concurrent feedback may represent coaching and inhibit progress towards independent practice.

c. Motor skill level of trainee - recognising the level of motor skill development is helpful in determining the required level of supervision and content of feedback. Motor skill stages have behavioral and neuropsychological correlates. Ideally the pre-trained novice has reached the intermediate stage of motor skill development. At the intermediate stage there is a degree of automaticity in the learners actions. We are more relaxed, have increased confidence and efficiency improves.

d. Zone of proximal development - When a registrar performs a task that is difficult enough that they require help from a tutor, it is described as being in the zone of proximal development. Tasks performed in this zone promote learning.

e. Scaffolding – is a term used to describe the support given to a registrar when they are performing a task in the zone of proximal development. Scaffolding also refers to support provided to control and monitor the clinical environment so that the trainee can focus on a specific skill.

f. Summary feedback – Feedback provided shortly after the procedure is completed. One method of initiating a discussion is to ask: “How do you think you performed?” Feedback should be targeted and focus on 2 -3 points including constructive feedback, positive feedback and identification of weaknesses.

Standardized pathways and the Perioperative Surgical Home

It is essential that regional anaesthesia is integrated into the modern paradigm of perioperative care. The modern paradigm of care includes programs such as Enhanced Recovery After Surgery (ERAS) and the Perioperative Surgical Home (PSH). The American Society of Anesthesiologists has proposed the PSH as a potential solution to the variability in both the cost and quality of perioperative care in the United States. (6) There is increasing demand to demonstrate value to patients, insurers and our patients. ERAS and PSH call for standardized, evidenced-based interdisciplinary perioperative pathways for commonly performed surgical procedures. Although PSH is likely to include ERAS pathways, the conceptual framework for PSH is more encompassing than ERAS. According to Kain, the PSH is a practice model that emphasizes superior coordination of care from the minute a decision to operate is made until 30 days after discharge. PSH aims to implement evidenced-based preoperative, intraoperative and postoperative protocols with minimal variability across an institution. Protocols will vary based on surgical services and will be tailored to the local environment. PSH will leverage data as a means to evaluate and improve all interventions in a continuous manner. Opportunities exist because of the vast amounts of information being collected from existing information technology infrastructure. (7) Length of stay and other metrics relating to cost are outcome measures that the PSH aims to collect. For example, in a total joint pathway developed for the PSH, the median length of stay for both total knee and hip arthroplasties was 3 (2-3) days, median (95% confidence interval). (6)  Of relevance to our current practice is that, these results (for length of stay) were obtained without the use of regional anaesthesia techniques traditionally used by  anaesthesiologists.

In many scenarios, the lack of controlled trials relevant to a clinical pathway make it difficult to definitively recommend a specific technique for a pathway and often, there are several anaesthetic and analgesic options. Therefore, we may rely on consensus statements and expert opinions. As far as possible, in the PSH all therapies that the patient are exposed to will be based on evidenced-based best practice. In addition, the goal of PSH is to minimise variability within a given institution in the perioperative therapies and interventions that patients are exposed to. The PSH therefore requires development of standardized pathways for each stage of the perioperative care for commonly performed operations.

In the table below are examples of components of a pathway for total joint arthroplasty. This structure contains content that is not meant to be definitive and in no way implies that there is consensus on many of the components of the pathway.

 

 


Use of regional anaesthesia for postoperative pain  control

The choice of technique may affect other elements of the pathway. Approaches are evolving as new techniques, equipment and drugs become available. The following table lists common sites used for regional anesthesia, along with benefits and drawbacks.

 

Other variables to consider for regional anaesthesia.

 

Surgical Anaesthesia

Options for surgical anesthesia are summarized in the table  below.

 

Intraoperative drugs

This may include first- and second-line antibiotics, preferred antiemetics for spinal anaesthesia versus general anaesthesia, and preferred sedatives for spinal or epidural anaesthesia.  Anticoagulation is usually started in the postoperative period by the surgery team, but may be commented upon here. Intraoperative dexamethasone appears to improve postoperative pain scores as well as proving an effective antiemetic. (42)

Intraoperative transfusion goals and blood conservation  options

Blood transfusion has risks (43) and one of the goals of the pathway may be to minimize blood loss and hence transfusion requirements. A wide variety of techniques are available to minimize blood loss, some of which are summarized in the table below.

Postoperative  pain control

Pathways often address pain control for patients with chronic pain or opioid use, as well as those without. Generally this section will comment on both the expected infusion regimens for continuous peripheral nerve blockade, (51) as well as adjuvants such as patient control opioid administration, ketamine, or other drugs.

Considerations regarding orthopedic surgical  pathway

Anaesthetic pathways need to comment upon ways in which they interact with the surgeon’s pathway, and make it clear why particular recommendations are made.

What  outcomes matter

Likely our sub-specialty will need to focus on long-term, more definitive and patient-centred outcomes including: 30-day mortality,37 disability free survival, (52) validated Quality of Recovery Scores,(53) robust measures of postoperative pain such as the Brief Pain Inventory, (54) hospital length of stay, re-admission rates and persistent post-surgical  pain. (55,56)

Having a broader perspective

Patient outcomes may benefit from anaesthetists’ having a broader perspective, collaborating outside of their specialty, incorporating a diverse set of viewpoints, backgrounds and skills. Vincent has eloquently outlined the benefits of multidisciplinary work, collaboration and exchange. (57) Dr Neuman (USA) has been awarded the 2015 American Society of Anesthesiology Presidential Scholar award.58 Recently, he also received $11.9 million funding from the Patient Centered Outcomes Research Institute for a major, multicenter pragmatic trial of spinal versus general anaesthesia for patients having surgery for fractured neck of femur. This proposal required engagement with a wide array of patients and stakeholders, including local elder advocacy organizations, the American Society of Anesthesiology and the Anesthesia Quality Institute, the U.S. Centers for Medicare and Medicaid Services, other organisations and professional societies; as well as 37 academic and community hospitals in the United States, Canada, and Australia. (58)

 

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CONTACT

Administrative contact

Please contact Karen Patching -
Desk phone: +64 (0) 9 375 7085
Email: karenp@adhb.govt.nz

c/- Department of Anaesthesia & Perioperative Medicine
Level 8 - Support Building, Auckland City Hospital
PO Box 92024, Auckland, New Zealand